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Washington University Experience | VASCULAR | Infarct - Acute | 10A0 Case 10 History
Case 10 History ---- The patient was a 59 year old woman S/P hysterectomy for endometrial adenocarcinoma with spread to lymph nodes. She did well and returned to work but had episodes of slowly progressive confusion with poor memory. The patient also had difficulty with speech which was described by her husband as "fragmented”. Cardiovascular examination revealed a 2/6 systolic ejection murmur at the apex radiating through the left sternal border. Brain CT with contrast was within normal limits. On 12/30 the patient became very lethargic and developed left hemiplegia and hyperreflexia. The patient continued to be unresponsive and had Kussmaul respiration. It was felt that the patient probably had pulmonary and cerebral emboli secondary to subacute bacterial endocarditis. EKG revealed an acute inferior lateral myocardial infarction. The patient was maintained on a respirator and expired several days later. ---- At autopsy there was a large recent infarct with softening and discoloration of the cerebral cortex, white matter and basal ganglia involving virtually the entire distribution of the right middle cerebral artery. Approximately 1 cm from its origin the right middle cerebral artery was occluded with a tough fibrous whitish appearing thrombus comparable in appearance to the cardiac valvular vegetations. In the left hemisphere there is a small focal cortical lesion in the lateral frontal lobe accompanied by a softening of the caudate and putamen near the external capsule. The left lateral occipital lobe also shows an acute infarct. The right and left cerebellar hemispheres show softening in the region of the superior cerebellar artery and the boundary zone at the left horizontal fissure. Many of the infarcts are associated with thromboemboli. These lesions also appear to be of various histologic ages. This patient demonstrates the classical neuropathologic consequences of nonbacterial thrombotic endocarditis (NBTE). At general autopsy, a mitral valve non-septic vegetation was identified. Numerous infarcts were also present in kidneys and spleen.
